State of California COMMUNITY-BASED ADULT SERVICES Department of Health Care Services
Health and Human Services Agency INDIVIDUAL PLAN OF CARE (IPC)
Participant Name: ______TAR Control Number (TCN): ______
Center Name: ______Provider Number (NPI): ______
Dates of Service (DOS): From: ______To: ______
NOTE: Definitions of all key words in this IPC can be found in the Medi-Cal Inpatient/Outpatient Provider Manual.
(1) Check box that applies to this IPC: O Initial TAR O Reauthorization TAR O Change TAR(#)______Planned Days/Week TB Clearance Date (initial TAR only): ______
The signature page of the History and Physical form accompanies this IPC and documents the request for CBAS services (initial TARs only). O Yes O No O NA
(2) DIAGNOSES AND ICD CODES
Primary Diagnoses
Include diagnoses as provided or confirmed by the personal health care provider(s) / ICD Code / Secondary Diagnoses
Include diagnoses as provided or confirmed by the personal health care provider(s) / ICD Code
1 / 1
2 / 2
3 / 3
4 / 4
5 / 5
6 / 6
(3)
MEDICATIONS
(frequency and dosage not required)
No Medications or Supplements
O / Active Prescriptions / 12
1 / 13
2 / 14
3 / 15
4 / 16
5 / Over-The-Counter Medications &/or Supplements
6 / 1
7 / 2
8 / 3
9 / 4
10 / 5
11 / 6
(4)
Active Personal Medical/Mental Health Care Provider(s) / Name / Address / Phone
Criteria Verification
· All circles checked must be supported by appropriate documentation in the participant’s health record.
· All information presented must be based on multidisciplinary team assessments completed at the center.
· All participants must meet the specified criteria of any one or more of the following categories (A thru E).
(5) Category A: For those individuals who meet Nursing Facility-A (NF-A) Level of Care (LOC):
Participant Does NOT Fall Within Category A
O / Ø Check circle if the participant does NOT fall within Category A.
Ø Check the circles next to the criteria indicating the participant meets the stated criteria.
1. Has been determined to meet the NF-A LOC or above; AND
2. Meets the following eligibility and medical necessity criteria:
a. 18 years of age or older and has one or more chronic or post-acute medical, cognitive, or mental health conditions, and a physician, nurse practitioner, or other health care provider has, within his or her scope of practice, requested CBAS services.
b. The person requires ongoing or intermittent protective supervision, skilled observation, assessment, or intervention by a skilled health or mental health professional to improve, stabilize, maintain, or minimize deterioration of the medical, cognitive, or mental health condition.
c. The person requires CBAS services, as defined in W&I Code, Section 14550 (BOXES 20, 22 and 23), that are individualized and planned, including, when necessary, the coordination of formal and informal services outside of the CBAS program to support the individual and his or her family or caregiver in the living arrangement of his or her choice and to avoid or delay the use of institutional services, including, but not limited to, hospital emergency department services, inpatient acute care hospital services, inpatient mental health services, or placement in a nursing facility or a nursing or intermediate care facility for the developmentally disabled providing continuous nursing care.
d. If a resident of an ICF/DD-H, the resident has disabilities and a level of functioning that are of such a nature that, without supplemental intervention through CBAS, placement to a more costly institutional level of care would be likely to occur.
e. Except for participants residing in an ICF/DD-H, the person must meet all of the following:
i. The participant has one or more chronic or post-acute medical, cognitive, or mental health conditions that are identified by the participant’s personal health care provider as requiring one or more of the following, without which the participant’s condition will likely deteriorate and require emergency department visits, hospitalization, or other institutionalization:
· Monitoring,
· Treatment or
· Intervention.
ii. The participant’s network of non-CBAS center supports is insufficient to maintain the individual in the community, demonstrated by a least one of the following:
· The participant lives alone and has no family or caregivers available to provide sufficient and necessary care or supervision.
· The participant resides with one or more related or unrelated individuals, but they are unwilling or unable to provide sufficient and necessary care or supervision to the participant.
· The participant has family or caregivers available, but those individuals require respite in order to continue providing sufficient and necessary care or supervision to the participant.
iii. A high potential exists for the deterioration of the participant’s medical, cognitive, or mental health condition or conditions in a manner likely to result in emergency department visits, hospitalization, or other institutionalization if CBAS services are not provided.
iv. The participant’s condition or conditions require CBAS services, on each day of attendance that are individualized and designed to maintain the ability of the participant to remain in the community and avoid emergency department visits, hospitalizations, or other institutionalization.
O
O
O
O
O
O
O
O
O
(6) CATEGORY B: For individuals who have an organic, acquired or traumatic brain injury and/or chronic mental illness:
Participant Does NOT Fall Within Category B
O / Ø Check circle if the participant does NOT fall within Category B.
Ø Check the circles next to the criteria indicating the participant meets the stated criteria.
1. Has been diagnosed by a physician as having an organic, acquired or traumatic brain injury, and/or has a chronic mental illness; AND
2. Meets CBAS eligibility and medical necessity criteria specified above in BOX 5, NUMBER 2; AND
3. The individual must demonstrate a need for assistance or supervision with at least:
a. Two of the following activities of daily living (ADLs)/instrumental activities of daily living (IADLs): bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management and hygiene; OR
b. One ADL/IADL listed above, and one of the following: money management, accessing resources, meal preparation, or transportation.
O
O
O
O
(7) CATEGORY C: For individuals with Alzheimer’s Disease or other dementia:
Participant Does NOT Fall Within Category C
O / Ø Check circle if the participant does NOT fall within Category C.
Ø Check the circles next to the criteria indicating the participant meets the stated criteria.
1. Individuals have moderate to severe Alzheimer’s Disease or other dementia, characterized by the descriptors of, or equivalent to, Stages 5, 6, or 7 Alzheimer’s Disease; AND
· Stage 5: Moderately severe cognitive decline. Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential.
· Stage 6: Severe cognitive decline. Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need extensive help with daily activities.
· Stage 7: Very severe cognitive decline. This is the final stage of the disease when individuals lose the ability to respond to their environment, the ability to speak, and, ultimately, the ability to control movement.
2. Meets CBAS eligibility and medical necessity criteria specified above in BOX 5, NUMBER 2.
O
O
(8) CATEGORY D: For individuals with mild cognitive impairment including moderate Alzheimer’s Disease or other dementia:
Participant Does NOT Fall Within Category D
O / Ø Check circle if the participant does NOT fall within Category D.
Ø Check the circles next to the criteria indicating the participant meets the stated criteria.
1. Individuals have mild cognitive impairment or moderate Alzheimer’s disease or other dementia, characterized by the descriptors of, or equivalent to, Stage 4 Alzheimer’s Disease, defined as mild or early-stage Alzheimer’s disease, characterized by one or more of the following; AND:
· Decreased knowledge of recent events;
· Impaired ability to perform challenging mental arithmetic;
· Decreased capacity to perform complex tasks;
· Reduced memory of personal history;
· The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations.
2. Meets CBAS eligibility and medical necessity criteria specified above in BOX 5, NUMBER 2; AND
3. The individual must demonstrate a need for assistance or supervision with two of the following ADLs/IADLs: bathing, dressing, self-feeding, toileting, ambulation, transferring, medication management, and hygiene.
O
O
O
(9) CATEGORY E: For individuals who have developmental disabilities:
Participant Does NOT Fall Within Category E
O / Ø Check circle if the participant does NOT fall within Category E.
Ø Check the circles next to the criteria indicating the participant meets the stated criteria.
1. Meets the criteria for regional center eligibility; AND
2. Meets CBAS eligibility and medical necessity criteria specified above in BOX 5, NUMBER 2.
O
O
(10) For those participants with a diagnosed chronic mental illness:
All participants with a primary or secondary diagnosis of chronic mental illness, pursuant to the California Code of Regulations, title 9, section 1830.205, as an included diagnosis for County Mental Health shall be provided information regarding availability of referral unless referral occurred prior to this TAR period. The CBAS center shall refer those participants that give consent for such referral. Check all that apply:
O No Mental Illness Diagnosis O Referral not Made (state reason):______
O Excluded Diagnosis ______
O Referral Made: Date:______
O Participant/Family Declined Referral ______
O Currently Being Served by County Mental Health
(11) ADL/IADL LIMITATIONS (Check only one box per row):
Independent
(able to perform for self with or without device) / Needs Supervision
(no physical help required but needs cuing or to be monitored, even with device) / Needs Assistance
(physical help required, even with device) / Dependent
(unable to do for self, even with physical help, cueing or device)
ADLs / ------/ ------/ ------/ ------
Ambulation / O / O / O / O
Bathing / O / O / O / O
Dressing / O / O / O / O
Self-Feeding / O / O / O / O
Toileting / O / O / O / O
Transferring / O / O / O / O
IADLs / ------/ ------/ ------/ ------
Accessing Resources / O / O / O / O
Hygiene / O / O / O / O
Meal Preparation / O / O / O / O
Medication Mgmt / O / O / O / O
Money Mgmt / O / O / O / O
Transportation / O / O / O / O
(12) CURRENT ASSISTIVE/ADAPTIVE DEVICES (Check all that apply):
O / None / O / AAC Device / O / Glasses or Other Vision Aid
O / Wheelchair / O / Orthosis/Prosthesis / O / Dentures
O / Walker / O / Gait Belt / O / Respiratory Equipment
(specify): ______
O / Crutches / O / Hoyer Lift / O / Other (specify): ______
O / Cane / O / Hearing Device
(13) CONTINENCE INFORMATION (Check all that apply):
O None
O Incontinent of bladder: O Occasionally O Frequently O Always
O Incontinent of bowel: O Occasionally O Frequently O Always
O External/internal catheter
O Ostomy
O Other (specify):
(14) FEEDING INFORMATION (Check all that apply):
O None O Overweight O Underweight O Feeding tube O Therapeutic/special diet
O Difficulty chewing and/or swallowing O Cannot feed self
O Other (specify):
(15) NON-CBAS CENTER SUPPORT/SERVICES (if known). (Check all that apply):
SUPPORT SERVICE / DESCRIBE
(how or why the support service is insufficient)
O / Not Known / Explain: ______
O / NONE / ------
O / IHSS/PCSP Services / Hours authorized per week/month: ______
O / Targeted Case Management / Frequency: ______
O / Other Paid Caregiver(s) / Frequency: ______
O / ICF/DD-H / Explain: ______
O / Lives in a Community Care Licensed Facility (e.g., Residential Care Facility) / Explain: ______
O / Participates in a HCBS Waiver
O MSSP
O Assisted Living
O NF A/B
O In-Home Operations (IHO)
O AIDS / Explain: ______
(16) NON-CBAS CENTER SUPPORT/SERVICES (if known). (Check all that apply):
Within the last 6 months, the participant received the following non-institutional services:
O Not Known. Explain: ______
______
O None.
O Home Health Agency Services. Explain: ______
______
Is the participant currently receiving Home Health Agency Services? O Yes O No
O Hospice Care. Explain: ______
______
Is the participant currently receiving Hospice Services? O Yes O No
If the participant is currently receiving either home health agency or hospice services, please specify:
Service / Frequency
O Urgent Care. Explain: ______
______
O Mental Health Services. Explain: ______
______
O Emergency Department. Explain: ______
______
O Other. Explain: ______
______
(17) RISK FACTORS (check all conditions that are demonstrated at the time of IPC completion)
O Inappropriate Affect, Appearance or Behavior O Dementia Related Behavioral Problems
O Poor Judgment O Fall Risk
O Medication Mismanagement O Isolation
O Self Neglect O Frailty
O Two or More Chronic Conditions O Other (specify):______
(18) AT RISK FOR ADMISSION TO ACUTE OR INSTITUTIONAL CARE (if known). (Check all that apply):
Within the last 6 months, the participant was admitted to the following level(s) of acute or institutional care:
O Not Known. Explain: ______
______
O None.
O Acute Care Hospital. Explain: ______
______
O Nursing Facility. Explain: ______
______
O ICF/DD or ICF/DD-N. Explain: ______
______
O Other. Explain: ______
______
Last Known Discharge Date from an Acute or Institutional Level of Care: ______
(19)
Yes No
O O / CBAS Core Services – all of these services are required each day of attendance: check Yes/No circle in the left-handed column for each service listed:
A. Professional Nursing Services
One or more of the following professional nursing services on each day of attendance:
N1 Observation, assessment, and monitoring of the participant’s general health status and changes in his/her condition, risk factors, and the participant’s specific medical, cognitive, or mental health condition or conditions upon which admission to the CBAS center was based.
N2 Monitoring and assessment of the participant’s medication regimen, administration and recording of the participant’s prescribed medication, and intervention, as needed, based upon the assessment and participant’s reactions to his/her medications.
N3 Oral or written communication with the participant’s personal health care provider, other qualified health care or social service provider, or the participant’s family or other caregiver, regarding changes in the participant’s condition, signs or symptoms.
N4 Supervision of the provision of personal care services for the participant, and assistance, as needed.
N5 Provision of skilled nursing care and intervention, within scope of practice, to participants, as needed, based upon an assessment of the participant, his/her ability to provide self-care while at the CBAS center, and any health care provider orders.
Yes No
O O / B. Personal Care Services/Social Services
One or both of the following core personal care services or social services on each day of attendance:
P1 One or both of the following personal care services:
P1a Supervision of, or assistance with, ADLs or IADLs.
P1b Protective group supervision and interventions to assure participant safety and to minimize the risk of injury, accident, inappropriate behavior, or wandering.
P2 One or more of the following social services provided by the CBAS center social worker or social worker assistant:
P2a Observation, assessment, and monitoring of the participant’s psychosocial status.
P2b Group work to address psychosocial issues.
P2c Care coordination.
Yes No
O O / C. Therapeutic Activities
One or both of the following therapeutic activities provided by the CBAS center activity coordinator or other trained CBAS center personnel on each day of attendance:
A1 Group or individual activities to enhance the social, physical, or cognitive functioning of the participant.
A2 Facilitated participation in group or individual activities for those participants whose frailty or cognitive functioning level precludes them from active participation in scheduled activities.
Yes No
O O / D. Meal Service
M At least one meal offered per day.
(20) TAR FOR REAUTHORIZATION OF CBAS SERVICES
Yes
O / No
O / NA
O / If this is a reauthorization TAR, the participant’s condition would likely deteriorate if the CBAS services were denied.
(21) Participant’s Individual Plan of Care (Core Services) (must be consistent with information provided in this IPC)